Spinal Infection – Causes, Symptoms and Treatments

Spinal infections can be classified by the anatomical location involved: the vertebral column, intervertebral disc space, the spinal canal and adjacent soft tissues. Infection may be caused by bacteria or fungal organisms and can occur after surgery. Most postoperative infections occur between three days and three months after surgery.

Vertebral osteomyelitis is the most common form of vertebral infection. It can develop from direct open spinal trauma, infections in surrounding areas and from bacteria that spreads to a vertebra from the blood.

Intervertebral disc space infections involve the space between adjacent vertebrae. Disc space infections can be divided into three subcategories: adult hematogenous (spontaneous), childhood (discitis) and postoperative.

Spinal canal infections include spinal epidural abscess, which is an infection that develops in the space around the dura (the tissue that surrounds the spinal cord and nerve root). Subdural abscess is far rarer and affects the potential space between the dura and arachnoid (the thin membrane of the spinal cord, between the dura mater and pia mater). Infections within the spinal cord parenchyma (primary tissue) are called intramedullary abscesses.

Adjacent soft-tissue infections include cervical and thoracic paraspinal lesions and lumbar psoas muscle abscesses. Soft-tissue infections generally affect younger patients and are not seen often in older people.

• Vertebral osteomyelitis affects an estimated 26,170 to 65,400 people annually.
• Epidural abscess is relatively rare, with 0.2 to 2 cases per every 10,000 hospital admissions. However, 5-18% of patients with vertebral osteomyelitis or disc space infection caused by contiguous spread will develop an epidural abscess.
• Some studies suggest that the incidence of spinal infections is now increasing. This spike may be related to increased use of vascular devices and other forms of instrumentation and to a rise in intravenous drug abuse.
• About 30-70% of patients with vertebral osteomyelitis have no obvious prior infection.
• Epidural abscess can occur at any age, but is most prevalent in people age 50 and older.
• Although treatment has improved greatly in recent years, the death rate from spinal infection is still an estimated 20%.

Risk factors for developing spinal infection include conditions that compromise the immune system, such as:

• Advanced age
• Intravenous drug use
• Human immunodeficiency virus (HIV) infection
• Long-term systemic usage of steroids
• Diabetes mellitus
• Organ transplantation
• Malnutrition
• Cancer

Surgical risk factors include surgeries of long duration, high blood loss, implantation of instrumentation and multiple, or revision, surgeries at the same site. Infections occur in 1-4% of surgical cases, despite numerous preventative measures that are followed.

Spinal infections can be caused by either a bacterial or a fungal infection in another part of the body that has been carried into the spine through the bloodstream. The most common source of spinal infections is a bacterium called staphylococcus aureus, followed by Escherichia coli.

Spinal infections may occur after a urological procedure, because the veins in the lower spine come up through the pelvis. The most common area of the spine affected is the lumbar region. Intravenous drug abusers are more prone to infections affecting the cervical region. Recent dental procedures increase the risk of spinal infections, as bacteria that may be introduced into the bloodstream during the procedure can travel to the spine.

Intervertebral disc space infections probably begin in one of the contiguous end plates, and the disc is infected secondarily. In children, there is some controversy as to the origin. Most cultures and biopsies in children are negative, leading experts to believe that childhood discitis may not be an infectious condition, but caused by partial dislocation of the epiphysis (the growth area near the end of a bone), as a result of a flexion injury.

Symptoms vary depending on the type of spinal infection but, generally, pain is localized initially at the site of the infection. In postoperative patients, these additional symptoms may be present:

• Wound drainage
• Redness, swelling or tenderness near the incision

• Severe back pain
• Fever
• Chills
• Weight loss
• Muscle spasms
• Painful or difficult urination
• Neurological deficits: weakness and/or numbness of arms or legs, incontinence of bowels and/or bladder

Patients may initially have few symptoms, but eventually develop severe back pain. Generally, younger, preverbal children do not have a fever nor seem to be in pain, but they will refuse to flex their spines. Children age three to nine typically present with back pain as the predominant symptom

Postoperative disc space infection may be present after surgery, occurring, on average, one month after surgery. The pain is usually alleviated by bed rest and immobilization, but increases with movement. If left untreated, the pain gets progressively worse and intractable, unresponsive even to prescription painkillers.

Adult patients often progress through the following clinical stages:

1. Severe back pain with fever and local tenderness in the spinal column
2. Nerve root pain radiating from the infected area
3. Weakness of voluntary muscles and bowel/bladder dysfunction
4. Paralysis

In children, the most overt symptoms are prolonged crying, obvious pain when the area is palpated and hip tenderness.

In general, symptoms are usually nonspecific. If a paraspinal abscess is present, the patient may experience flank pain, abdominal pain or a limp. If a psoas muscle abscess is present, the patient may feel pain radiating to the hip or thigh area.

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Seek medical care if symptoms of a spinal infection are present. Early diagnosis and treatment can prevent progression of the infection and may limit the degree of intervention required to treat the infection. Delaying care may result in progression of the infection causing irreversible damage to boney and soft tissue structures of and around the spine.

Signs of spinal infection emergency (Seek care immediately):

• Development of new neurological deficits, such as weakness of arms or legs and/or bowel/bladder incontinence.
• Fever not controlled with medication.

The biggest challenge is making an early diagnosis before serious morbidity occurs. Diagnosis typically takes an average of one month, but can take as long as six months, impeding effective and timely treatment. Many patients do not seek medical attention until their symptoms become severe or debilitating.

Laboratory Tests

Specific laboratory tests can be useful in helping to diagnose a spinal infection. It may be beneficial to get blood tests for acute-phase proteins, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Both ESR and CRP tests are often good indicators as to whether any inflammation is present in the body (the higher the level, the more likely it is that inflammation is present). As inflammation is the body’s natural response to infection, these markers can monitored to assess the presence of infection and the effectiveness of treatment. These tests alone however, are limited, and other diagnostic tools are usually required.

Identification of the organism is essential, and this can be accomplished through computed tomography-guided biopsy sampling of the vertebra or disc space. Blood cultures, preferably taken during a fever spike, can also help identify the pathogen involved in the spinal infection. Proper identification of the of the pathogen is necessary to narrow the antibiotic treatment regiment.

Imaging Tools

Imaging studies are necessary to pinpoint the location and extent of a lesion. The choice of specific imaging techniques varies slightly, depending on the location of the infection.

Computed Tomography Scan (CT Scan)

The degree of bone destruction is best imaged on a CT scan. Vertebral osteomyelitis can destroy the vertebral body and lead to spinal deformity (typically kyphosis). By assessing the degree of boney destruction, the amount of spinal instability can be determined and can aid in deciding between non-surgical and surgical treatment options.

The CT scan above shows vertebral osteomyelitis at L3-L4 resulting in destruction of the L3 and L4 vertebral bodies. The second CT shows a thoracic spinal compression fracture due to osteomyelitis causing a kyphotic deformity of the spine.

Magnetic Resonance Imaging (MRI)

MRI with and without gadolinium contrast enhancement has become the gold standard in identifying spinal infection and assessing the neural elements. MRI allows for visualization of the soft tissues that include the nerves, spinal cord, and paraspinal muscles, and adjacent soft tissue around the spinal column. Enhancement of the vertebral body, disc space or epidural space is a key sign of infection; however, other pathologies such as inflammation or tumors must be ruled out.

Spinal infections often require long-term intravenous antibiotic or antifungal therapy and can equate to extended hospitalization time for the patient. Immobilization may be recommended when there is significant pain or the potential for spine instability. If the patient is neurologically and the spinal column is structurally stable, antibiotic treatment should be administered after the organism causing the infection is properly identified. Patients generally undergo antimicrobial therapy for a minimum of six to eight weeks. The type of medication is determined on a case-by-case basis depending on the patient’s specific circumstances, including his or her age.

Nonsurgical treatment should be considered first when patients have minimal or no neurological deficits and the morbidity and mortality rate of surgical intervention is high. However, surgery may be indicated when any of the following situations are present:

• Significant bone destruction causing spinal instability
• Neurological deficits
• Sepsis with clinical toxicity caused by an abscess unresponsive to antibiotics
• Failure of needle biopsy to obtain needed cultures
• Failure of intravenous antibiotics alone to eradicate the infection

The primary goals of surgery are to:

• Debride (clean and remove) the infected tissue
• Enable the infected tissue to receive adequate blood flow to help promote healing
• Restore spinal stability with the use of instrumentation to fuse the unstable spine
• Restore function or limit the degree of neurological impairment

Once it is determined that the patient requires surgery, imaging tools such as plain x-rays, CT scans or MRI can help further pinpoint the level at which to perform surgery.

Proper and timely follow-up is necessary to ensure that the spinal infection has been controlled and is responding to the treatment protocol. Repeat lab work and imaging studies should reflect improvement in the infection. CT and x-ray studies will allow the surgeon to assess the integrity of the boney structures of the spine and ensure that spinal instrumentation has not failed.

Current treatment protocols for spinal infections require treatment by a multidisciplinary team of physicians, including infectious disease experts, neuroradiologists and spine surgeons. The team will be able to assess the best treatment approach on an individualized basis, whether it is surgical or nonsurgical.

Case Example: Osteomyelitis of L3 and L4 vertebral bodies

MRI (left) and CT (middle) scan showing osteomyelitis of the L3 and L4 vertebral bodies causing destruction of the spinal column. This leads to spinal instability and compression of the lumbar nerve roots. Patient underwent surgery for debridement of the L3 and L4 vertebral bodies and implantation of a titanium graft, pedicle screws, and rods to reconstruct the spinal column (right).

Shashank V. Gandhi, MD; Michael Schulder, MD, FAANS
Department of Neurosurgery
Zucker School of Medicine at Hofstra/Northwell
Manhasset, NY

The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS’ Find a Board-certified Neurosurgeon online tool.

Spinal Infection Symptoms & Treatment | Mount Sinai

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Conditions

Spinal infections are rare, but, when they happen, they can be destructive if not treated promptly and properly. Infections can occur in the spinal bones or vertebrae in the soft discs that cushion each vertebra or in the soft tissue around the spine. At Mount Sinai, we address any spinal infections promptly and carefully.

Spinal Infection Symptoms

Different types of spinal infections produce different symptoms. Here are some of the primary spinal infections and symptoms:

• Cervical spine infections cause neck pain, stiffness, and decreased range of motion.
• Intervertebral disc space infections lead to severe back pain, fever, chills, weight loss, muscle spasms, and painful or difficult urination.
• Spinal canal infections often produce severe back pain, tenderness, and fever.
• Adjacent soft-tissue infections may trigger abdominal pain, pain in your upper abdomen or back (flank pain), or pain radiating to the hip and thigh.

Potential Causes of Spinal Infections

Bacterial or fungal infections can spread to the disc from elsewhere in the body, causing urinary tract infections or other infections.

Once the infection has passed through and out of the rest of your body, the infection often remains in the disc and may cause it to weaken, decay, and collapse. When this happens, the disc pushes against the spinal nerves, causing pain. If not treated, the infection can spread to the vertebrae, weakening the bones and causing them to collapse and press against the spinal cord, which can affect many body functions. If the infection is still not treated, the deformed vertebrae can fuse, press against the nerve roots, and lead to continuous pain.

Diagnosing Spinal Infections

It can take a month or more to diagnose a spinal infection. Diagnostic tests include bloodwork to identify whether an infection is present and imaging tests to pinpoint the exact location and extent of the issue. Imaging tests typically include magnetic resonance imaging (MRI) and computerized tomography (CT) scan.

Spinal Infection Treatment

We treat spinal infections with both surgical and non-surgical techniques.

Non-surgical treatments include long-term intravenous antibiotic or antifungal therapy, often involving extended hospitalization.

If non-surgical techniques do not resolve the issue, physicians may perform surgery to clean and remove the affected tissue, enable the infected area to maintain adequate blood flow, maintain or restore spinal stability, and limit neurological impairment.

Lumbar puncture – preparation, indications and performance of a puncture in Moscow

Lumbar puncture is performed to collect cerebrospinal fluid (CSF) (synonymous with CSF) that bathes the brain and spinal cord. Normally, viruses, bacteria, inflammatory cells – leukocytes, and oligoclonal antibodies should not be detected in the cerebrospinal fluid. If we find any pathological agent in the cerebrospinal fluid, then it becomes possible to accurately determine the cause of the disease. For example, the detection of oligoclonal antibodies and the 2nd type of their synthesis makes it possible to establish the diagnosis of multiple sclerosis with a high probability.

How is the procedure carried out?

The patient is asked to lie on his side, bend his head and press his bent knees to his stomach, ie. assume the fetal position. Sometimes the puncture is done in a sitting position, then they are also asked to lean forward as much as possible. Flexion of the back is necessary in order to increase the distance between adjacent vertebrae in the lumbar region and to reduce the distance from the skin to the spinal canal. Before the puncture, local anesthesia is performed. I perform a puncture in the lower back into the space between the spinal processes of 5 or 4 lumbar vertebrae. You may feel some discomfort during the insertion of the needle, but there is usually no pain due to local anesthesia. After the needle enters the spinal canal, cerebrospinal fluid begins to drain from the lumen of the needle. Usually 3-5 ml of liquid is taken. The entire procedure usually takes about 10 minutes. Within a day or two after the puncture, discomfort at the injection site may disturb. However, pain is more likely associated with the irritating effect of the anesthetic than directly with microtrauma when the needle is inserted. They try to perform the puncture in the morning in order to have time to send the CSF sample to the laboratory.

Is it possible to damage the spinal cord during a puncture?

Despite the fact that the needle is inserted into the space where the spinal cord is located, its injury is excluded during the standard CSF collection procedure in adults. The fact is that the spinal cord fills the canal throughout only in infants. The growth of the spine significantly outstrips the growth of the spinal cord, so the latter, as it were, “lifts up”, and its lower border is at the level of the 1st lumbar vertebra. The remaining space is a fluid-filled sac that contains the spinal nerve roots that travel down to “their” foramina in the spine. It is as difficult to damage a spine with a needle as it is to pierce vermicelli in broth with a needle. Trauma to the intervertebral disc is excluded, since the needle is inserted from the opposite side of the vertebra.

What side effects can be expected after the puncture?

The most common (approximately 20% of patients) adverse effect of a lumbar puncture is headache. A decrease in CSF pressure can cause irritation of the meninges containing pain receptors. This pressure drop is most significant when moving to a vertical position. Therefore, immediately after the puncture, it is necessary to lie down for 2 hours. Also, over the next 2-3 days, it is recommended to exclude physical activity and, if possible, lie down 2-3 times a day for 30 minutes. Headache occurs in an upright position and disappears in a horizontal position. Conventional pain medications for post-puncture headache are usually ineffective, the best treatment is to lie down.

How much CSF is taken during a lumbar puncture?

Total adult CSF volume is 140 to 270 ml. 600-700 milliliters of fluid are produced daily, that is, the cerebrospinal fluid is completely renewed about 4 times a day. During a lumbar puncture, 3-5 ml of fluid is usually removed. Thus, the extracted volume of CSF is rather insignificant in comparison with the total volume of its circulation. It is preferable to perform a lumbar puncture with the thinnest possible needle so that CSF does not leak through the puncture. To quickly replenish the volume of cerebrospinal fluid, you can speed up its production. To this end, it is recommended to take a sufficient amount of liquid (at least 2 liters of mineral water per day), as well as coffee (2-3 cups per day).

How important is a lumbar puncture?

Although lumbar puncture is an invasive procedure, it is generally well tolerated, no more painful than blood sampling, and the diagnostic information obtained after lumbar puncture is invaluable. And this, in turn, speeds up the diagnosis and allows you to prescribe treatment as early as possible.

Lumbar puncture in Moscow at the Moscow Multiple Sclerosis Center

There are many negative opinions about lumbar puncture. But these are precisely the opinions of non-specialists, many of whom have not had a lumbar puncture at all. “This is a very painful procedure”, “the puncture cannot be done – it is very harmful”, “the legs will fail”, “you will not be able to walk”, “you will have meningitis” and much more can be heard from our patients and read on the Internet. But in reality, these words are groundless. First, lumbar puncture is a routine procedure throughout the world. In recent years, the range of diseases has significantly expanded, in which a lumbar puncture is performed, followed by analysis of the cerebrospinal fluid (CSF). Multiple sclerosis and other demyelinating diseases, motor neuron disease, polyneuropathy, dementia, Alzheimer’s disease, CNS tumors are diseases that require a lumbar puncture to be diagnosed.

How is a puncture done

What does a puncture provide for diagnosis?

After this procedure, we get liquor (stress on the first syllable). Liquor is a fluid (also called cerebrospinal fluid) that bathes the brain and spinal cord. It has a unique composition, we know which substances should be normal and which should not be. We can determine their number. Moreover, in various diseases, due to changes in the brain and spinal cord, substances begin to appear in the cerebrospinal fluid that directly indicate which CNS cells die and by what mechanism. All this information for the doctor is invaluable. It will allow you to distinguish between certain diseases that are very similar to each other in manifestations (symptoms), confirm or accelerate the diagnosis.

What can we detect in the cerebrospinal fluid in multiple sclerosis?

The primary diagnosis of multiple sclerosis is no longer complete without a lumbar puncture. Of course, it can not be carried out, but, because. there are many similar diseases, without a puncture it is possible to be mistaken in the diagnosis. In addition, if you have radiologically or clinically isolated syndromes, then the analysis of cerebrospinal fluid allows you not to wait for the next exacerbation, and together with the MRI data, you can establish a diagnosis much faster and prescribe treatment much faster. And we know that starting therapy earlier increases its effectiveness and is more likely to slow down the accumulation of disability in the future.

So, we remember that with multiple sclerosis, autoimmune inflammation occurs in the central nervous system. Immune cells enter the inflammation zone (which we see on MRI as an active focus) and begin, among other things, to produce antibodies. Antibodies belong to the class of immunoglobulins. In the cerebrospinal fluid, immunoglobulins are normal, their small amount corresponds to the spectrum of immunoglobulins in the blood. Those. we have a great many (millions) of antibodies to various bacteria, viruses, etc. in our blood. Each antibody is found in approximately equal concentrations in the blood, and when we do an analysis, we find many small peaks – “noise” from antibodies. The same “noise” is detected in the liquor. Then we say that both in the cerebrospinal fluid and in the blood (serum) the synthesis of antibodies is polyclonal (normal, type 1 synthesis). But in multiple sclerosis, when autoimmune inflammation occurs in the brain and spinal cord, in the focus of this inflammation, immune cells (B-lymphocytes) begin to produce antibodies of a certain specificity (to myelin). These antibodies penetrate into the cerebrospinal fluid (but not into the blood), and in the analysis there is one very large peak against the background noise, indicating that the concentration of one antibody (out of millions) has increased dramatically. I repeat, since inflammation occurs precisely in the central nervous system, the concentration of these specific antibodies appears there, but not in the blood. Then we see that the synthesis of immunoglobulins in the blood serum remains “noisy”, polyclonal, and an increased level of certain immunoglobulins appears in the cerebrospinal fluid – oligoclonal synthesis. This combination of polyclonal synthesis in blood serum and oligoclonal synthesis in CSF is referred to as type 2 synthesis or simply oligoclonal. If oligoclonal antibodies are detected in the cerebrospinal fluid, then this confirms multiple sclerosis with a very high degree of probability. But if oligoclonal immunoglobulins are not detected, then this does not reject the diagnosis – such a collision. The method is very specific, but may not be very sensitive. Why is this happening? It depends on the activity of inflammation in the CNS: if active foci are detected on MRI, then oligoclonal antibodies appear in the cerebrospinal fluid (if these foci are due to multiple sclerosis). And if there are no oligolonal immunoglobulins in the presence of active foci in the cerebrospinal fluid, then doctors think very strongly that there may be a diagnosis different from multiple sclerosis. If there are no active foci, then the absence of oligoclonal antibodies does not exclude the diagnosis, because. the amount of their production may be insufficient for the appearance of a peak of oligoclonal immunoglobulins. But still more often, if you already have multiple sclerosis, there are no active foci on MRI, then oligoclonal antibodies will still be detected in the cerebrospinal fluid.

In addition to detecting oligoclonal antibodies, the analysis of cerebrospinal fluid makes it possible to exclude other causes, other diseases: viral, bacterial damage, i. e. infection, and other demyelinating diseases.

How is a puncture performed?

First, the procedure is painless: it is performed under local anesthesia. You will not feel pain, only a small prick with a thin needle when lidocaine or other local anesthetic is injected. The very introduction of the puncture needle will be painless. When it enters the spinal canal, it is rare, but it happens that the needle touches the spinal root passing in the canal (it does not damage it, but it touches it). In this case, for a fraction of a second, you may feel a shot along the spine, usually in the leg.

Secondly, the puncture is not made into the spinal cord, but into the spinal canal containing the spinal cistern. The spinal cord is a thin cord that ends at the level of the last, 12th thoracic or first lumbar vertebrae. Next come only the spinal roots. We insert the needle significantly below the point of termination of the spinal cord – between the 4th and 5th lumbar vertebrae. Therefore, if performed correctly, there can be no damage to the spinal cord, and hence weakness of the legs.

The procedure itself is performed lying on your side or in a sitting position. After the introduction of lidocaine between the fourth and fifth vertebrae, a special puncture needle is inserted into the spinal cistern. Inside the needle there is a lumen, into which the cerebrospinal fluid begins to flow. Liquor is collected in a volume of 2-4 ml in special test tubes and sent to the laboratory. Usually the result is required to wait from 5 to 10 days.

After the puncture, lie down on your side or stomach, preferably without a pillow for two hours, longer if possible. When the “freeze” goes away, you may feel a little soreness at the puncture site, which will completely disappear the next day. The next day or the day after, a post-puncture headache may occur – the only complication after a puncture. Headache does not always occur, in a smaller proportion of patients, more often in young people, lasting from one day to a week.